Healthcare Provider Details

I. General information

NPI: 1225155245
Provider Name (Legal Business Name): FAMILY SERVICES OF NORTHEAST WISCONSIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 SPIRIT WAY
GREEN BAY WI
54304-5687
US

IV. Provider business mailing address

300 CROOKS ST
GREEN BAY WI
54301-4527
US

V. Phone/Fax

Practice location:
  • Phone: 920-330-0339
  • Fax: 920-330-9060
Mailing address:
  • Phone: 920-436-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number1005260
License Number StateWI

VIII. Authorized Official

Name: THOMAS MARTIN
Title or Position: PRESIDENT-CEO
Credential:
Phone: 920-436-6800